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MCCQE 1 Preparation. Paediatric Orthopaedics Dr. Ken Kontio. Outline. Exam content mainly Common / bread n`butter topics Meat and potatoes Questions?. Case. 7 month old presenting with leg concern Mother noticed left leg shorter to finger assisted standing

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Mccqe 1 preparation

MCCQE 1 Preparation

Paediatric Orthopaedics

Dr. Ken Kontio


  • Exam content mainly

    • Common / bread n`butter topics

    • Meat and potatoes

  • Questions?


  • 7 month old presenting with leg concern

  • Mother noticed left leg shorter to finger assisted standing

  • Exam shows Ortilani/Barlow tests neg, mildly decreased Abduction left hip, mild LLD with left shorter than right

    • What do you think is going on?


  • Xrays legs to find site of shortening

  • U/S hips to diagnosis possible DDH (dislocation)

  • Xray hips to confirm dislocation hip

  • Give shoe lift for better posturing

  • Pavlik harness for obvious hip dislocation clinically


  • Commonest paediatric hip problem early on

  • Presentation may be very benign

    • Decreased abduction most sensitive after 3-6mo

  • Exam : Ortolani + for dislocated hip

    Barlow + for dislocatable hip

  • Workup U/S early (<3mo)

    • Ossification femoral epiphysis 3-6 mo

    • Xray later due to void defect from ossification

  • DDH

    • Treatment

      • Dislocated - reduction, confirmation, pavlik

      • Dislocatable - immediate post birth, repeat later

        - later, pavlik

        Pavlik continues until normal U/S or Xray (AI<22º)

  • Late may need CR (spika) older than 6 mo

  • Later may need surgery, older than 1 year (painless limp-todler or less)

  • Long term follow for normal acetabular development (surgery if no AI in 18mo)

  • Case

    • 6 year old boy with pain in the Rt knee

    • Limps at end of day, no complaints of pain

    • Exam shows mild limp,

    • Knee exam normal

    • What to Do?


    • Give tensor for sore knee

    • Xray knee to rule out fracture

    • Examine hips for source of problem

    • MRI knee to rule out meniscal pathology

    • Tap knee for possible infection


    • Hip concern in child 4-8 years

    • Commonly knee pain as presenting complaint

      • If leg pain always think about hip pathology

    • Presentation

      • Painless limp

      • Decreased ROM (esp. Abd, IR)


    • X-Ray

      • Unilateral or mixed stage bilateral

      • Epiphyseal ossification abnormalities

    • Tx

      • Maintain ROM

      • Coverage issues

      • Self limiting

      • Head sphericity key to long term outcome


    • Most common cause of hip problems in adolescents

    • Some able (stable) and some not able (unstable) to walk

    • Obligatory ER hip with flexion

    • If not teen consider outliers (endocrine disorders, renal disease)

    • Xray needed to make diagnosis


    • Workup

      • Xrays show slipped neck-head interface

    • Tx

      • All need protection

      • All need treatment

      • Pin(s) across slip

      • Closure about 6-12 months

      • Watch for avn


    • Congenital types need progress documented to prove progressive nature

      • Rule our renal (U/S) or cardiac (Echo) involvement

    • Infantile AIS, more boys, left convex thoracic curves

      • Many resolve on their own


    • Juvinile and adolescent curves

      • Right thoracic and left lumbar curve directions

      • Risk of progression 1º maturity related

    • Presentation

      • Painless, if painful consider spinal pathology


    • Treatment

      • 0-25(30) observe

      • 25(30)-45(50) brace

      • 50 or more consider surgery

      • Brace used until maturity

      • Surgery to correct and prevent progression


    • 4 year old boy presents with pain in his hip and a low grade fever.

      • Limp started two days earlier

      • Progressive difficulty walking

      • Temperature 37.6 (oral), ROM hip irritable

      • Xray hip normal, WBC mildly increased, ESR up about 35 (0-20)

      • What is your plan of management?


    • Give him NSAID and follow up in 1 week

    • Start Abx and admit for observation

    • Start Abx and admit for hip arthrotomy / washout

    • U/S of hip and start antibiotics

    • Admit for bone scan and start antibiotics

    • U/S hip, aspiration/ arthrotomy , start antibiotics

    Infection vs inflammation
    Infection vs Inflammation

    • Often asked to differentiate between joint involvement (bacterial vs “viral”)

    • Spectrum of findings

      • Walking painless limp to bedridden, painful

      • Workup best to rule out options

        • Sensitive but not specific

        • Labs, xrays, physical exam

      • Radiology

        • U/S of joints, Bone scans of bones


    • Presents as benign picture

    • Little systemic evidence of infection

    • Recent illness common (URTI)

    • Tx

      • Watch for worsening

      • Workup to rule out other problems

      • Arrange close follow-up


    • Active picture clinically

    • Workup suggestive but not localizing

    • If joint fluid, obligated to sample

    • If no fluid, bone scan to rule out osteo

    • Antibiotic therapy only after samples and treatment (if surgery) carried out

    • Deep infection needs deep treatment


    • If near joint can mimic septic arthritis (Especially acetabular infection)

    • Pain, fever, minor guarding if at all of joints

    • Blood cultures, radiographs, then IV Tx before getting bone scan

    • Weird things such as salmonella common in sickle cell disease, but Staph Aureus still most common in this population


    • Salter –Harris classification

      • II most common

      • III-IV intra-articular requiring anatomic reduction

      • V diagnosed after arrest seen


    • If displaced and healing

      • Accept up to 20-30 degrees angulation in plane of joint in young child (<10yrs)

      • Healing time same, remodelling time about 1 degree /month

    • If SH injury (I-II)

      • After 7-10 days do not manipulate for risk of iatrogenic injury to growth plate

    General principles
    General Principles

    • A/B/C

    • Hx

      • timing, mechanism, weight-bearing, last meal, allergies

    • PE

      • deformity, bleeding, open wounds, bruising, distal pulse, neurological motor and sensory (2-pt discrimination) exam

    • immobilization

      • the unstable fracture needs immobilization before imaging (any fracture really)

    • analgesia

      • oral/sc/IV

    General principles1
    General Principles

    • Investigation

      • plain film:

        • 2 views 90 degrees apart including joints above and below

        • oblique or additional views for certain body parts:

          • cervical vertebrae, hand, ankle, foot, phalanges

      • Bone scan

        • more sensitive in certain settings e.g scaphoid fractures

      • CT

        • helps define complex fractures e.g. intra-articular fratures

      • MRI’s role continues to expand

        • delineates surrounding tissue injuries e.g. spinal cord compression

    General principles2
    General Principles

    • Fracture Description

      • clinical:

        • age, sex, mechanism, anatomy, NV status, associated injuries

      • radiographic:

        • anatomy

        • pattern (longitudinal, transverse, oblique, spiral, impacted, comminuted, bowing, greenstick, torus)

        • Displacement (angulation and translation)

        • shortening

        • joint or growth plate involvement

    General principles3
    General Principles

    • Orthopedic Consultation

      • general indications

        • open, unacceptably displaced, neurovascular compromise, significant joint or growth plate


      • specific indications

        • non-avulsion pelvic fractures, femur fractures,

        • dislocation of major joints (not shoulder),

          spinal fractures

    Special considerations
    Special Considerations

    • Open fracture

      • Td, IV Abx, never suture (tightly) overlying skin, ortho consult

    • Compartment Syndrome

      • need not be a significant fracture (or no fracture)

      • pain with passive extension is the earliest sign

    • Pathologic Fracture

      • tumors e.g. osteosarcoma

      • hereditary diseases e.g. osteogenesis imperfecta

      • metabolic diseases e.g. rickets

      • neuromuscular diseases e.g. Muscular Dystrophy

      • infectious diseases e.g. osteomyelitis

    Special considerations1
    Special Considerations

    • Child Abuse

      • features strongly suggestive of abuse

        • fractures inconsistent with the history

        • fractures inconsistent with the child’s developmental age

        • multiple fractures, specially in various stages of healing

        • fractures in those less than 1 year-old

        • mid-diaphyseal periosteal elevation

        • epiphyseal or diaphyseal rib fractures

        • spiral fractures in non-ambulating children

        • epiphyseal-metaphyseal fractures:

          • corner fractures

          • bucket handle fractures

      • Skeletal survey required in suspected cases

    Corner fractures
    Corner Fractures

    • 2-month-old female

    • to ER for decreased movement of the left leg

    • according to the mother, the infant cries a lot when she is dressed

    • the step-father told her that while he was cleaning the house, he tripped over the infant's brother and accidentally stepped on the baby

    Bucket handle fracture
    Bucket Handle Fracture

    • 9 m.o. is to ER when it was noted something is wrong with the infant's arm after a toy was pulled away from him

    • infant was in the care of the baby-sitter at that time.



    Good Luck…Relax!!